Guidelines for Opioid Use in the ED

Colorado’s Story: Colorado Opioid Safety Pilot

Diane Rossi MacKay, MSN, RN, CPHQClinical Manager, Quality ImprovementColorado Hospital Association

Partners

Background

Need:CHA hospitals requested support for opioid work

Opportunity:Pain is the #1 reason for

ED visits

Solution: Colorado ACEP 2017 Opioid Prescribing &

Treatment Guidelines first in the nation to promote alternatives to opioids in

multiple ED’s

Colorado ACEP Guidelines

Colorado ACEP 2017 Opioid Prescribing & Treatment Guidelines

Guidelines for opioid use in the emergency department

Four Pillars

1. Limiting opioids from the ED

2. Alternatives to opioids for painful conditions (ALTOs)

3. Harm reduction

4. Treatment for addicted patients and referral

ALTOs – Colorado ACEP Guidance

1. Non-opioid medications first

2. Opioids as rescue therapy

3. Multimodal and holistic pain management

4. Pathways:

◦ Kidney stones

◦ Low back pain

◦ Fractures

◦ Headache

◦ Chronic abdominal pain

Objectives

GOAL AIM

Reduce administration of opioids by 15 percent

as measured in morphine equivalent

units (MEUs).

Reduce administration of opioid medications in ED by implementing the

Colorado ACEP 2017 Opioid Prescribing &

Treatment Guidelines.

Pilot Overview

• 10 pilot sites identified hospital lead and team members

• CHA, steering committee and subject matter experts provided: ◦ Technical assistance

◦ Order sets

◦ Stocking guidance

◦ Educational support

◦ Peer trainings

◦ Data support

◦ Analytics platform

◦ Regular data review

◦ Marketing and communication

◦ Internal and external communication templates

Measures

Opioids Used

Total administration (in MEUs)/1,000 ED

visits

Total number of treated pain

visits/1,000 ED visits

ALTOs Used

Total administrations/ 1,000 ED visits

Total number of treated pain

visits/1,000 ED visits

ED HCAHPS Responses

How well was your pain controlled?

Would you recommend this

ED?

Colorado ALTO Project 2018Ten Pilot Sites

Participating ED Characteristics

Critical Access

20%

Freestanding EDs20%

Acute Care60%

Hospital Type

Urban70%

Rural30%

Location

None20%

Level IV30%

Level III10%

Level II 30%

Level 110%

Trauma Designation

Annual ED visit range: 4,164 – 59,753 (median = 26,297)

Licensed bed range: 0 – 408

(median = 169)

Overall Results

31% in ALTO

administration

35,000fewer projected

opioid administrations during the pilot than during the baseline

period

36% in opioid

administrationMeasured in

MEUs/1,000 ED visits across all 10 EDs

2017 vs. 2016

Overall Results

* Reductions in MEUs/visit decreased throughout the pilot period

Overall Results – by Site

Overall Results – ALTO Use

ALTO vs. Opioid Use Over Time

Change in Medical Administration

Lidocaine Use

Ketamine Use

Acetaminophen and Ibuprofen Use

Hydromorphone Use

Total Unique Visits by Diagnosis

ALTO

Opioid

Patient Satisfaction

ED Specific HCAHPS Questions:

1. How well was your pain controlled?

2. How likely are you to recommend this ED?

There were no significant differences in HCAHPS scores between the baseline and project period.

Limitations

1. Small pilot with significant support

2. No control hospitals

3. Limited assessment of balancing measures: ◦ ED length of stay

◦ Adverse reactions or outcomes related to ALTO usage

Conclusions

Colorado ACEP 2017 Opioid Prescribing &

Treatment Guidelines are

effective in reducing opioid usage.

The Colorado Opioid Safety Pilot ED ALTO approach should be disseminated statewide.

Significant change to clinician culture

regarding pain treatment.

ALTOs for pain in the ED is a

feasible and effective strategy.

Colorado Opioid Safety Pilot Next Steps

Complete analyses and disseminate results

Assist pilot hospitals with sustainability plans

Provide support from CHA and Colorado ACEP for Colorado EDs implementing the ALTO approach

Identify additional venues for implementation (e.g., promote out-of-state adoption)

Colorado ALTO Project

Need:CHA hospitals requesting support for opioid ALTO

work

Opportunity:Leverage ED pilot ALTO

success to hospitals across the state

Solution: CHA and collaborating

partners provide support for Colorado hospitals

seeking to implement ALTO approach

Colorado ALTO Project 2018

Regional train-the-trainer sessions begin Spring, 2018

Hospitals Showing InterestOriginal Pilot Sites

You save lives every day … Thank you.